Provider Demographics
NPI:1669763702
Name:PHILLIPS, JACQUELINE M (MD)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:M
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:M
Other - Last Name:BORS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2979 WOODSIDE RD
Mailing Address - Street 2:
Mailing Address - City:WOODSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:94062-2443
Mailing Address - Country:US
Mailing Address - Phone:650-851-4747
Mailing Address - Fax:650-851-4343
Practice Address - Street 1:2979 WOODSIDE ROAD
Practice Address - Street 2:
Practice Address - City:WOODSIDE
Practice Address - State:CA
Practice Address - Zip Code:94062
Practice Address - Country:US
Practice Address - Phone:650-851-4747
Practice Address - Fax:650-851-4343
Is Sole Proprietor?:No
Enumeration Date:2011-04-24
Last Update Date:2018-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA125544208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics